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PubMed2005

Neurobiological background for performing surgical intervention in the inferior thalamic peduncle for treatment of major depression disorders.

OBJECTIVE: To present a review of evidence for an inhibitory thalamo-orbitofrontal system related to physiopathology of major depression disorders (MDDs) and to postulate that interfering with hyperactivity of the thalamo-orbitofrontal system by means of chronic high-frequency electrical stimulation of its main fiber connection, the inferior thalamic peduncle (ITP), may result in an improvement in patients with MDD. METHODS: Experimentally, the thalamo-orbitofrontal system has been proposed as part of the nonspecific thalamic system. Under normal conditions, the nonspecific thalamic system induces characteristic electrocortical synchronization in the form of recruiting responses that mimic some sleep stages. It also inhibits input of irrelevant sensory stimuli, thus facilitating the process of selective attention. Permanent disruption of the system, via lesioning or temporary inactivation through cooling of the ITP with cryoprobes, results in a state of hyperkinesia, increased attention, and cortical desynchronization. RESULTS: Surgical lesioning of the medial part of orbitofrontal cortex and white matter overlying area 13, which includes the ITP, may result in significant improvement in MDD. Imaging studies (functional magnetic resonance imaging and positron emission tomography) consistently demonstrate hyperactivity in the orbitofrontal cortex and midline thalamic regions during episodes of MDD. This hyperactivity decreases with efficient control of MDD by medical treatment, indicating that orbitofrontal cortex and midline thalamic overactivity are related to the depressive condition. Conversely, noradrenergic and serotoninergic systems in the frontal lobes have been implicated in the pathophysiology of MDD. Although noradrenergic receptor density in the frontal lobe is consistently increased in depressed patients who commit suicide, 5-hydroxytryptamine reuptake blockers, which are potent antidepressive drugs, decrease hypermetabolism in the orbital frontal cortex in MDD. Therefore, the serotonin hypothesis for depression postulates that norepinephrine and serotonin in the frontal lobes are required to maintain antidepressive responsiveness. Dysregulation of the secretion of both neurotransmitters initiates overactivity of orbitofrontal cortex, resulting in depression. It is possible that surgical interventions in this region, including electrical stimulation of ITP, disrupt adrenergic and serotoninergic dysregulation in patients with MDD. CONCLUSION: Circumscribed lesions or electrical stimulation of the ITP, a discrete target easily identified by electrophysiological studies, may improve MDD. Electrical stimulation may have the advantage of being less invasive and more adjustable to patient needs.

Animals↗
PubMed1990

Health care delivery and professional effectiveness: centralization, staff admission, surgical performance and decision making.

Professional power and professional effectiveness in hospitals is a little investigated but very critical phenomenon. The problem with any investigation on power is the many variables which are involved and the complex way in which they manifest themselves. This paper tests the hypothesis of potential redundancy among these variables. The null hypothesis was rejected in favour of the alternative hypothesis, concluding that the original nine variables contained redundancies and could be replaced with four non-redundant factors. The implications for future research in this area are stated.

Centralized Hospital Services↗
PubMed1985

A consensus process to determine the relative complexity-severity of frequently performed surgical services.

Current prevailing fees represent initial charges inflated over time, and it is well known that some services, such as surgical treatment of the coronary arteries, are less demanding services today than in the early days of the specialty, when morbidity, mortality and operative stress were extremely high. Resource costs are difficult to measure accurately and time is an inappropriate indicator of complexity and severity. If society is looking for ways in which physicians will support changes in reimbursement, the C-S index resulting from the consensus process which has been described herein could provide an acceptable basis for a variety of payers to assess services. We plan to validate this consensus method in other geographic areas and will report the results in appropriate publications. We hope that the C-S index will be valuable in future policy discussions about the basis for physician fees, as well as for other health policy purposes.

Costs and Cost Analysis↗